197610227-1-15-2025-31-AS-GSAO-DCXS6E-20250115123549

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610227
Report Date: 01/15/2025
Date Signed: 01/15/2025 12:36:28 PM

Document Has Been Signed on 01/15/2025 12:36 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	GARDEN GROVE ASSISTED LIVING, INC		FACILITY NUMBER:	197610227
ADMINISTRATOR/ DIRECTOR:	GASPARYAN, ANNA		FACILITY TYPE:	740
ADDRESS:	8525 GARDEN GROVE AVENUE		TELEPHONE:	(818) 678-9858
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91325
CAPACITY: 6		CENSUS: 5	DATE:	01/15/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:20 AM
MET WITH:	Vitalina Bezdolna		TIME VISIT/ INSPECTION COMPLETED:	12:40 PM

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On 01/15/25 at 9:20 AM, Licensing Program Analyst (LPA) Gina Saucedo, arrived to conduct an unannounced, annual inspection at the facility. Upon arrival, LPA Saucedo met with caregiver Vitalina Bezdolna and disclosed the purpose of the visit. The caregiver called the administrator but the administrator could not come to the facility at the time.

LPA asked for the census, resident, and staff files.

A physical tour was conducted at 10:40 AM and observed the following:

The Kitchen area was toured, and LPA observed there to be sufficient seven (7) day supply of non-perishable foods and perishable food for all residents. The kitchen area was clean at the time of the tour. The fire extinguisher is located against the wall on your right-hand side, leading to the living/dining room area. It is fully charged. The fire extinguisher was bought 01/30/2024. There is extra, food in the kitchen pantries. The sharps are locked and inaccessible to the residents in one of the top cabinets on your right-hand side. The medication is at the bottom of one of the cabinets locked and inaccessible on your right-hand side of the kitchen. The first aid kit is on the kitchen counter.

The garage is detached from the house. The garage has an extra refrigerator. There is extra incontinence, beds and water in the garage.

Outside/Backyard: The outside/backyard has furniture for residents with proper seating. The facility has a signal system. The facility does have a pool fenced and locked inaccessible to the residents.

LIC 809C-continued

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:	DATE: 01/15/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: GARDEN GROVE ASSISTED LIVING, INC	FACILITY NUMBER: 197610227
	VISIT DATE: 01/15/2025

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Bedrooms: There are four (4) bedrooms and two (2) bathrooms. Three (3) of the bedrooms are single, occupied and one (1) bedroom shared with a private bathroom. All bedrooms and bathrooms were toured and were properly furnished and have appropriate bedding, linens, toiletry, and lightning. Both bathrooms have proper toiletry and grab bars. The bathroom temperatures of the water are within regulations reading at 115-117-degree Fahrenheit.

The dining area/living room area is located next to the kitchen where there is enough seating for the residents and the staff. There is a large television and there is also internet access.

There is an office area towards the back exit and there is a partition for the staff. The telephone line is located in this area.

There are cabinets in the hallway that have extra linen. The house temperature is at 76-degree Fahrenheit.

The carbon monoxide and smoke detectors are located throughout the facility and are operable.

There is one (1) washer and dryer, and the chemicals are stored with them locked and inaccessible to the residents in care located on your left side of the kitchen. The Ombudsman sign is located on your left- hand side against the wall.

Administrative: At the entrance of the facility there is a YES sign, facility sketch, Rights of Resident Council, Personal Rights, Disaster Plan, Non-Discriminatory Policy, Visiting Rights, Report of suspected adult/elderly abuse. The surety bond has an expiration date of March 2025, there is a license that states RCFE/DEMENTIA residents. There is a binder with the Infection Control and Fire drill.

An exit interview was conducted, no citation(s) were issued, and a copy of this report was given to the Caregiver and emailed to Administrator.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:	DATE: 01/15/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025

LIC809 (FAS) - (06/04)

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